Public Safety / Government RegistrationWho should register? Fire, EMS, OES, Public Health and any Government Agency that performs a Homeland Security function. Notification e-mail address must be agency affiliated. (Please, no personal e-mail addresses.)
CONTACT INFORMATION(for registration purposes only)First Name *Last Name *Position/Title/Rank: *Phone Work: (###-###-####) *Mobile Phone: (###-###-####) E-mail: * (use agency/organization email address)WEBSITE ACCESSPassword: *Create a password for website access(Minimum 8-characters 1-special 1-numeric)Do you have Security Clearance?: Yes -Select- SECRET TOP SECRET N/A NoCleared Through:FBI DOD DHS N/AIf cleared through other state below:
AGENCY / ORGANIZATIONAgency/Organization Name: *If your agency does not appear on the above list, complete the Full Agency Name below.Other Agency/Organization Name:Federal State Local Military OtherCity: *County: *- Select your county -AlamedaContra CostaDel NorteHumboldtLakeMarinMontereyNapaMendocinoSan BenitoSan FranciscoSan MateoSanta ClaraSanta CruzSonomaOtherState:*
Professional License # *EMT / EMTP / RN or N/A: *SUPERVISOR / EMPLOYMENT VERIFICATION CONTACTFull Name:*Supervisor's Title*Phone Work:* (###-###-####) Supervisor's Email Address:* (Organization email addresses only)Confirm Your Supervisor's Email Address:*
All registration information is considered strictly confidential.
2. I hereby acknowledge that I have read the attached document, titled "Safeguarding Sensitive but Unclassified Information" and a copy has been provided to me, and that I have received a security indoctrination concerning the nature and protection of FOUO information, including the procedures to be followed in ascertaining whether other persons to whom I contemplate disclosing this information have been approved for access to it, and that I understand these procedures.
3. I have been advised that the unauthorized disclosure, unauthorized retention, or negligent handling of FOUO information by me could cause damage or irreparable injury to the NCRIC. I hereby agree that I will never divulge FOUO information to anyone unless: (a) I have officially verified that the recipient has been properly authorized by the NCRIC to receive it; or(b)I have been given prior authorization from the agency responsible for the information that such disclosure is permitted; or (c) the recipient has the "need to know" in order to perform their official duties. I understand that if I am uncertain about the classification status or handling control authority of information received from the NCRIC, I am required to confirm from an authorized NCRIC official that the information is FOUO before I may disclose it, except to a person as provided in (a) or (b) above.
4. I have been advised that any breach of this Agreement may result in the termination of my affiliation with the NCRIC.
5. I have read this agreement carefully and my questions, if any, have been answered.